Category Archives: Concussion

There is a paucity of quality concussion education in entry level, residency, and post-professional medical education.

Why?

Because there is no evidence based medicine for concussion.

A bold statement as I introduce what I believe to be the worlds first yearlong, multidisciplinary, and post-professional concussion education program for clinicians.

Let me start with a story:

It was the week I got promoted to junior partner of my company.

The week I took a deep breath for the first time in my life and said “OK Schwartz…You’ve arrived.”

I was surrounded by people whom I genuinely cared about, professionally and personally, and I felt like my nose to the grindstone personality the last 13 years of formal didactic education, business mentorship, and the chase to this finish line had come to fruition.

That was the week I was hit by a car.

That was the week my life changed forever.

On October 3, 2013, I went from being Dr. Schwartz to patient 237427 in a NYC Emergency Department getting rolled through a CT Scan.

It’s a difficult journey being on “the other side of healthcare.”

I was that patient rolling to CT with my MD Calculator in hand who was able to recite the Canadian CT Head Rules like a proud elementary school student who had just learned her speaking part for the school play.

Physical therapy was my craft. I was mastering the craft of treating the patient as person, developing my patient rapport tools, building a wonderful international referral network, and understanding the nuances of running multiple successful businesses.

I loved every minute of it. The more I learned the more I wanted to learn.

A one week medical leave of absence turned into 10+ hours of rehabilitation a week for a year.

How could an injury so seemingly benign change my life forever?

What We Know:

In 1997, the CDC reported 300,000 concussions in the United States. In 2016, the CDC estimates are 1.6-3.8 million sports related concussions based off of the most recent 2006-2010 data.

I strongly believe that these numbers continue to be greatly underestimated based off of the heterogenous nature of this injury, underreporting[1-4], ~25% of people not seeking emergency department or other medical care[5], and lack of an agreed upon definition and consensus on what the injury is in the literature[6-8].

We know that approximately 20-30% of patients develop persistent symptoms crossing over into the post concussion syndrome threshold each year with ranges from 5-58% in the literature[9-11].

If we look at ~30% of all concussions crossing over into the persistent symptom category, that is 1.14 million people in the United States based off of the current data alone.

Remember, I continue to believe that this data continues to be grossly underestimated.

The Gaps:

We know that TBI is grossly underfunded yet it is a major cause of death and disability in the United States, contributing to about 30% of all injury deaths[12].

According to the National Institutes of Health (NIH), Cancer research received $5.6 Billion in 2015. Comparatively and up from $88 million in 2015, TBI is estimated to receive just $91 million in 2016[13]. Approximately 5.6 million people are living with the long terms effects of TBI and 138 deaths occur per day[12] amounting to ~50,000 deaths per year in the US. In 2015, there were 1,658,370 new cancer cases diagnosed and 589,430 cancer deaths in the US[14].

Why compare cancer and TBI? Because cancer has made huge gains by breaking down cancer. We don’t treat cancer. We treat large cell non-Hodgkin lymphoma. We need to do the same in the concussion community.

Scientifically, we must start with agreeing upon a universal definition of concussion, mTBI, and TBI. From there we need to be able to break down the injury appropriately based off of neurophysiological changes and injury to specific areas of the brain. While these are lofty goals, I also don’t see this being tangible in the near future nor is it clinically and functionally relevant to the patient seeking care in front of us today.

The above statistics indicate that we are doing much better at saving patients lives from severe cases of TBI vs cancer; however, the true burden exists with TBI survivors suffering from the lasting effects of what a TBI does to a person as a whole being.

We know that 100% of all neuroprotection phase III studies are negative, less than 5% of New Medical Entities (NME) in clinical assessment make it to FDA approval, and 100% of all Phase III trials in TBI are negative.

This means that there have been zero phase three clinical trials in TBI that have moved on to completion, there are zero drugs for TBI, and that TBI and concussion are strictly a clinical diagnosis.

We have to do better. And we can.

Medical Education and Healthcare:

Daniel Goleman discusses the key concept of “iatrogenic suffering” in medicine. This is an added anguish by medical personnel delivering insensitive messages that can often engender more emotional suffering than the actual illness itself[15].

Historically in medicine if we do not understand an injury or disease pathway, we prescribe rest or send the patient to a psychologist e.g. syphillis, low back pain, B12 deficiency, cardiac issues in women, etc.

We’ve missed the mark in the concussion community as medical providers. Over the last few decades, we’ve allowed the medico-legal literature to get ahead of us in the medical community.

It wasn’t until 1989, a neuropsychologist by the name of Jeffrey Barth, was part of the first group to suggest that cognitive testing in preseason athletes may have some value due to concussive injuries presenting lasting effects.

We’ve enabled a culture of “I got my bell rung” to prevail and have not addressed concussion from a systems level until recently.

I’ve heard time and time again that “We can’t teach it because there’s no empirical evidence”.

Nonsense.

As I was being well-cared for by my team of physicians and clinicians, I continued to do my best to take a step back and look at the inner workings of the healthcare team, system and educational offerings that are made available to all clinicians from physician to PT et al.

When I learned that 2015 was the first year that neurology residencies were receiving formal didactic education in concussion within the ‘Behavioral Neurology’ section springing from the work and advocacy of the Sports Neurology Section of the American Academy of Neurology, I knew there had to be something done.

A change.

A change in the global architecture of medicine with respect to the concussion patient of today.

A concussive injury is an all hands on deck injury. It can often require a team of clinicians to identify, treat, and manage this patient population.

Concussion patients port of access to the clinician of today is infinite. It can range from the athletic trainer, the emergency department physician, the primary care physician, the pediatrician, the nurse practitioner, the physician assistant, the school nurse, psychologist, physical therapist, occupational therapist, speech therapist, and anyone who has direct access to the patient of today.

I emphatically deliver this message when I speak publicly: it is not a matter of if you treat concussion patients. It is a matter of when you will encounter, treat, and/or refer a concussion patient.

A concussion is not a broken bone. That’s easy. We know normal tissue healing parameters in healthy populations.

A concussion is a neurophysiologic injury that can affect all domains of a person’s life from somatic, cognitive, emotional, vestibular, sleep, and behavior often with non-specific answers to the all important patient question of “when will I get better?”

It is gut-wrenching as a clinician to have the self awareness to look into a patient’s eyes and say “I don’t know.” It is even more painful as a patient to be completely unaware of if you will ever get better when you are being cared for by one of the best clinicians in the world.

We can do better. And we will. Here’s how.

Healthcare Teams:

Long gone are the days of the one physician model, yet we seem to be in a conundrum when it comes to communication and teamwork in medicine.

In the fall of 2014, I had the privilege to virtually attend the International College of Residency Education’s (ICRE) opening plenary delivered by rhetorician scientist Dr. Lorelei Lingard on Collective Competence: Adapting our concept of competence to healthcare teams[16].

During this time, I was finalizing my concussion rehabilitation and Dr. Lingard’s words helped facilitate my eureka moment of how I can aide in providing a solution to this medical world of specialists all attempting to treat the same poorly defined and heterogenous injury.

Summatively, she states that individual competence does not equal good healthcare.

She elaborates reviewing a case scenario describing the maze of disconnected care episodes that the patient of today is experiencing.

Dr. Lingard states that we need to “evaluate in situ, broaden focus beyond individual actions to include inter-actions among individuals, capture the ‘cracks’ between the care episodes, and consider interactions among elements of the system, not just among people…Competence is a way of ‘seeing’ that both directs and deflects our attention. The cracks between care episodes, experts cultivating collective competence ‘know how the system usually fails in this situation, and plans accordingly.’ Our attention is directed towards individual competence and deflected from collective competence. We need both[16].”

My role is to facilitate collective competence in the concussion community.

Let’s think about the concussion patient of today.

A concussed individual can experience any one of the following myriad of symptoms all at once or over a period of time [See Chart].

Each of these symptoms can be managed by individual specialists that may or may not cohesively integrate their treatment models with a co-treating clinician.

Concussion identification, treatment, management, and having the self awareness to know when and whom to refer appropriately can be a complex team model and clinical algorithm.

Each concussion case is unique and treatment models are 100% situationally dependent.

Kenneth Burke, an American literary theorist, once said that “every way of seeing is a way of not seeing.”

We can’t simply “treat the headache” or “treat the balance issue.” Treating the concussion patient of today involves a complex series of evaluations across all domains in order to systematically identify injury deficits in order to appropriately make the decision of what to treat, when to treat it, and when to refer appropriately.

If you treat together, you must learn together.

Here’s how.

Rapport and Clinician Synchronicity:

“To feel with, stirs us to act for[15].”

Get in-synch with your concussion patients.

These patients often feel very disconnected to the medical community. Patient stories of seeking care from 5+ medical providers until they “find their person” in healthcare is not uncommon.

Rapport is key to successful patient, provider and caregiver interactions. When people are in rapport, their physiology actually attunes. Robert Rosenthal published a landmark article revealing the central tenets of “relationship magic,” the recipe for rapport. This only exists when three elements are present: mutual attention, shared positive feeling, and a well-coordinated nonverbal duet. As these three emerge cohesively, we spark rapport[15].

This is how lifelong patient-provider and provider-provider relationships are formed.

Nature is based upon energy and timing. Basic science has identified symbiosis throughout the natural world ranging from the firing of an action potential to the marvelous making of what happens between winter and spring.

Concussion is an injury of asynchronous firings at a cellular level which accumulate amounting to a functional dysfunction with ones self and environment.

Original Concept by Jessica Schwartz; Rendered by Chris Freeman

We need to learn how to adapt to the needs of our patients who carry a host of pre and post morbid medical conditions and circumstances presenting with the complexities that the heterogenous nature of a concussive injury presents.

This 12-month program provides the latest clinical conversations, evidence-based guidelines, and consensus statements while integrating real world experiences from patients, providers, and caregivers who have navigated the complex healthcare network of today.

Content delivery is both interactive and dynamic, exposing the student to some of the most influential clinicians in the concussion community coupled with the unique learning experience of provider to provider, patient to provider, and caregiver to provider storytelling.

By fostering a rehabilitative team approach, the EIM Concussion Certification hopes to facilitate collective competence across the healthcare continuum in order to better triage, treat, and appropriately refer the concussion patient of any age from acute to chronic stages.

This year long multidisciplinary concussion certificate sets the learner up for success utilizing an asynchronous and synchronous online learning environment for the busy post professional of today.

The in-person weekend intensive reviews the psychomotor properties of the concussion evaluation, treatment, management, and referral options based off of the providers scope of practice during the 12 month didactic education experience.

As a pre-requisite to the program, each post-professional student will undergo a therapeutic neuroscience education course. As we embark on a multidisciplinary educational journey together, I sincerely believe that we all speak the same language of medicine; however, we bring many different dialects to the clinical table.

I will utilize the TNE course to cohesively meld the post-professional multidisciplinary EIM Concussion students in language, compassion, and competency of the therapeutic neuroscience evaluation in order to jumpstart their experience of learning together in a new environment.

A few months before physician Kenneth Schwartz died, he stated that “Quiet acts of humanity have felt more healing than the high dose of radiation and chemotherapy that hold the hope of a cure. While I do not believe that hope and comfort alone can overcome cancer, it certainly made a huge difference to me[15].”

I hope to create kind, compassionate, and clinically efficient clinicians who foster rapport with patients, interdisciplinary colleagues, and across disciplines.

Care for the concussion patient. Care for him/her together. And care for him/her well.

The Faculty:

I’ve been fortunate enough to have returned back to patient care and have surrounded myself with some of the brightest and most dedicated faculty in the world in their respected specialties.

Over the last year, the energy that I’ve felt from this group of men and women has been palpable. I am honored everyday to have worked with and continue to collaborate with each and everyone of these passionate clinicians.

What do they all have in common? I systematically screened all interviewees for passion, high IQ, high EQ, and low ego who have the self awareness to take a step back from themselves and look at the big picture of clinical care.

We have a tall order in front of us and I know we’re here to do our best to help clinicians of today put our best foot forward to educate each other and our communities of coaches, parents, spouses, teachers, caregivers, and loved ones on the multifaceted injury that concussion can present itself as to the provider and patient of today.

Why Story?:

Paul Zak, a neuroeconomist, eloquently stated “Stories are powerful because they transport us into other people’s worlds but, in doing that, they change the way our brains work and potentially change our brain chemistry — and that’s what it means to be a social creature[17].”

Storytelling allows us to step back, view, and listen from an aerial and reflective standpoint while creating the neural groundwork of patient exposure by connecting to the story, the provider, the caregiver, and the patient.

Schwartz Rounds were invented by an ill physician who also experienced the dichotomy of both doctor and patient. His purpose was to facilitate understanding of how the patient perceives their own illness and treatment by deploying empathy and building rapport[15].

If we have no empirical data, then we need to learn from each other. I believe by deeply listening to each other, patients, and caregivers fosters an excellent way to change the way in which we begin to shift the global architecture of medicine with respect to the concussion patient of today.

How can we help and treat a mutual patient if we don’t sincerely understand what each of us can collectively do for one another in the best interest of the patient.

Story allows us to experience the injury through the eyes of experienced providers, patients, and caregivers who have navigated the complex healthcare system of today.

Concussed: Collective Competence in Healthcare

and the Patient Experience

On May 16, 2015, I had the privilege to speak in front of 200 of my colleagues at Evidence in Motion’s 3 day hands-on and didactic learning festival, Manipalooza, at the University of Colorado’s Anshutz Medical Campus in Denver, Colorado.

If I had to sum the entire weekend up in one word it would be:

Inspired.

Topics of discussion and practical application included concussion, neuroscience, biases in healthcare, manipulation, pelvic health, workplace safety, advanced soft-tissue mobilization, and an epidemiological review of low back pain: where it’s been, where we are going, and how the physical therapist is leading the way.

I have learned that when you are surrounded by some of the top minds in the world who collectively come together with two interests in mind: 1. How to immediately make the clinician better for next day patient care and 2: the importance of being connected to oneself, as provider, including self-awareness of biases and our past patient/life experiences which in turn correlate to increased self-management increasing efficacy in and out of the clinic…it’s well, inspiring.

This low-ego, incredibly fun, and contagiously charismatic group of doctors, clinicians, and scientists was truly an impressive group to be a part of in all domains to engage with, learn from, and disseminate knowledge to a hungry audience of motivated professionals.

May 16, 2015 was particularly profound for me because I essentially got to go public with my story for the first time…and who better to present to than “my own people”, Physical Therapists.

The Schwartz adaptation of the David Sackett’s, MD Evidence Based Medicine (EBM) triangle including patient experience. I encourage all clinicians to listen to and learn from our patients stories. We can learn so much by deeply listening to our patients as people first.

I was in a motor vehicle accident October 3, 2013 and my life changed forever. I underwent a year of rehabilitation living with post-concussive syndrome. I had the good fortune to be cared for by the incredible team of physicians, non-physician doctors, and clinicians at the New York University Concussion Centerfor 10+ hours a week for about a year of rehabilitation and guidance so I could successfully Return to Life with my new abilities.

I said it time and time again during my physical, orthopedic, neurologic, and cognitive rehabilitation throughout the year… “if I don’t share this story with the medical community it’s essentially malpractice in my eyes”. I continue to hold strong to these goals and values of transparency, story-telling, and sharing of my own personal journey with the goal of increasing concussion patient-provider connectedness in the medical community.

I have one goal: facilitate collective competence amongst the healthcare community in order to better identify, treat, and manage the concussion patient along the entire continuum of recovery from acute to chronic.

I was able to update the audience on some of the latest happenings in concussion research and development, review some stigmas associated with post-concussive syndrome, present my case revealing the patient was myself about half way through the presentation, share some poignant moments of what it was like to live through post-concussive syndrome, and announce the Evidence in Motion Concussion Certificate Program for the post-professional medical provider.

I am absolutely thrilled to be leading this program with the key concept of instilling collective competence across the healthcare continuum so we as clinicians can 1. better understand the scope of everyones interdisciplinary practice, 2. increase abilities to identify commonly missed post-concussive symptoms (cognition, vision, vestibulo-ocular, persistent pain, etc), 3. empower the provider to feel confident in his/her abilities when evaluating, treating, and appropriately referring the concussion patient to a colleague as needed, and 4. empower the provider to educate the community from sports leagues, coaches, parents, school districts, fellow medical professionals, care-takers, employers, and patients.

A key theme of my professional being and future lecture series as it pertains to the concussion patient is built around the concept that there is no one provider who can comprehensively treat this population of patient. My core clinical values foster interdisciplinary knowledge translation. How can we refer to one another if we sincerely don’t have a grasp of what each of us across the healthcare continuum can do for one another as provider and for our mutual patient? I would like to facilitate this forward and collective thinking necessary to provide the concussion patient the best possible care.

Faculty will include some of the top minds, researchers, and clinicians in the world collectively coming together to educate the post-professional academic learner. Faculty will include the neurologist (adult and pediatric), emergency medicine physician, vestibular physical therapist, traumatic head and neck disorder scientists, occupational therapist/vision therapy, neurogenic speech language pathologist, board certified sports clinical specialist physical therapist, certified athletic trainer, neuroscientist, and the neuropsychologist.

Specialty topic areas will include: Pediatrics, Geriatrics, Sports, Trauma, and the Service Member/Veteran.

Collectively, these incredibly bright and motivated minds will come together and I, as program director, will bridge the gaps empowering the clinician along the course of one year to become comfortable with their clinical abilities, their interdisciplinary colleagues, and most importantly- this cohort of concussion patient who is so often mismanaged in this maze of disconnected care episodes that healthcare system of today has unfortunately bred.

Concussion and Nutrition Series Part III:

The Most Promising Nutrients for Affecting TBI Outcomes and Recommendations for Patients

As Traumatic Brain Injuries (TBIs) continue to lead to a third of all injury-related deaths in the United States each year, researchers remain at a loss for a drug to treat them. The fact that brain injuries vary depending upon the location, type, intensity, and duration of force make them difficult to study and an even bigger challenge for the healthcare practitioner making recommendations for appropriate care.

The concept that the brain is an impressionable organ affected by its environment is finally gaining acceptance. Much remains to be discovered, but nutrition as a preventive intervention is a practical and safe proposal. The ability of nutrients to interact with a variety of physiological processes associated with TBI suggests that including nutritional approaches as a complementary therapy when managing a brain injury could be beneficial.

In 2011, the Institute of Medicine (IOM) published a report entitledNutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. In the report, the committee cites the most promising connections between specific nutrients and TBI. Nutrients are suggested based on the evidence behind their ability to affect physiological processes involved in TBI. Those nutrients deemed most likely to be effective target four main mechanisms- decreasing brain swelling, decreasing inflammation and oxidation, decreasing cell death and increasing energy production.

Choline, creatine*, omega-3 fats, zinc, magnesium and Vitamin D were identified as the most promising nutritional interventions, although more research is warranted. Table 1 below explains their modes of action, foods highest in nutrient density, and an easy way to prepare a dish high in them. I encourage you to share this with your patients and colleagues.

There is a double edged sword when conducting studies as supplementation is necessary for researchers to separate the nutrient of interest from the other nutrients in food. However, it can lead the public to assume that supplementation will be effective for their health.

When considering the connection between brain injuries and nutrition, it is helpful to separate acute versus long term symptomatic events. Supplementation may be beneficial to improve treatment outcomes immediately after the injury as a high turnover of nutrients required. However, for those most at risk for traumatic brain injuries (i.e. athletes, motor vehicle accident survivors, etc) and for those that experience long-term symptoms, whole foods such as fruits, vegetables, nuts, fish and legumes may be a better option for acquiring resilience.

We have to also be cognoscente and connected to our patients that have no intention or ability to eat well. A supplement may be indicated, but it should be emphasized that it won’t replace the enhanced benefits they’ll get from whole foods. Our bodies evolved to respond to whole foods and all of the benefits they have to offer- not just one specific nutrient. Prescribing them offers not only fiber, energy, satiety but also the brain-boosting effects of so many other vitamins, minerals and protective substances (see Evidence Behind Flavonoids and Their Role in Anti-Inflammatory Foods) that are missing in a supplement.

*Creatine is created in our bodies and there are few foods that contain it. Therefore, they are not listed on the chart. Supplementation may be beneficial immediately after injury and requires further scientific investigation.

Concussion and Nutrition Series Part II: Effects of a High Fat, Low Carbohydrate Diet on Brain Metabolism

With respect to nutrition and concussion, there isn’t concrete evidence that there is one type of diet or panacea to aide with concussion symptoms due to the multi-system nature of this injury.

The intention behind this article is not to propose that you, as a healthcare provider, prescribe a defined diet to concussion patients or even to recommend it as an alternative therapy. Simply, it is to encourage you to consider the evidence behind the idea that (1) what we eat affects the body; and (2) nutrition may be more powerful in healing than many of us have been taught to believe.

The ketogenic diet.

What is it? Who is it prescribed for? And why has this prescribed diet continually intrigued me as it correlates to concussion patients. The ketogenic diet was developed to mimic starvation and has been used and studied for almost an entire century [1]. It is a high-fat diet in which carbohydrates are all but eliminated (less than 50g per day). For reference, there are 27g of carbohydrates in a banana. It is presently most commonly used to control epileptic seizures especially in children [1-3]. More recently, researchers have some evidence that the diet may be effective for improving traumatic brain injury (TBI) outcomes as well [14].

Let’s take a look at how the ketogenic diet works. The brain craves carbohydrates. Whenever they are available, the brain will use them for energy- before breaking down fats and certainly before breaking down protein. When a patient is on a ketogenic diet, carbohydrates aren’t available. The brain settles and breaks down fats instead, converting triglycerides into fatty acids and ketone bodies– the ketone bodies are then used to make ATP and fuel the brain cells. In fact, they may even be a more efficient source of energy than glucose [1]. But how might this translate to protecting the brain?

Ketone bodies were found to prevent neuron cell death in a variety of studies through many different mechanisms [1]. Most of them used animal models so the effectiveness in humans requires more investigation. However, ketogenic diets are highly effective in treating epilepsy [4], so we do know that the brain is most certainly affected by the diet.

We also know that processes in TBI associated neuronal death include energy (ATP) depletion, reactive oxygen species (ROS) production, and inflammation. Since ketone bodies are an alternative source of energy, they are thought to lessen the harmful effects of energy depletion that occur with injury. Multiple studies have shed light on their ability to increase the cell’s resistance to oxidation, inflammation and programmed cell death [5-10]. One caveat is that the diet may be more effective in children – adherence is easier and younger brains are better at transporting and utilizing ketone bodies [11-13].

If the ketogenic diet has so much fat, you may be wondering about health-related consequences. Over the long term, it was actually found to decrease the level of triglycerides and LDL cholesterol while increasing HDL cholesterol. On the contrary, gastrointestinal disturbances are common and children on the diet may be at slightly higher risk for stunted growth, bone fractures and kidney stones. Supplements are prescribed by a medical professional to counter deficient micronutrients [13].

There are a lot of unknown variables with respect to this diet in humans living with TBI. Do short periods on the diet lead to long-term benefits or are the effects reversible? Should the diet be administered right after the injury? What time window is most effective? Are low glucose levels necessary or could you administer ketone bodies without the need to restrict carbohydrates?

A better understanding might provide insights into therapeutic approaches that eliminate the need for strict adherence to diet that is difficult to maintain. Ideally, the ketogenic diet could inform scientists developing a drug that is effective in treating TBI.

Presently, the best course of action a healthcare professional can take with regards to nutrition is to prescribe patients with TBI an increased intake of fruits and vegetables in conjunction with their present course of treatment. Fruits and vegetables are full of flavonoids and antioxidants which have been found to have positive impacts on concussion outcomes and are a more feasible alternative to carbohydrate restriction. See Concussion and Nutrition Series Part I: Evidence Behind Flavonoids and Their Role in Anti-Inflammatory Foods for a comprehensive review.

New York, NY September 19, 2014- As an orthopedic residency trained doctor of physical therapy who is passionate about my career in medicine, injury prevention and knowledge translation in academic medicine, it was a humbling experience to be surrounded by such an enthusiastic, knowledgeable and emotionally intelligent group of people advocating for one common goal: Youth Sports Safety.

During the pilot-phase (Fall 2014) MomsTEAM Institute has selected leading researcher coordinators who are working with the following universities to bring the SmartTeams program into their communities: AT Still (AZ), University of Tennessee, University of Texas, Michigan State, University of South Carolina and the University of Tulsa.

In collaboration with and input from all relevant youth sports stakeholders, the Institute has been designing and developing a set of comprehensive health and safety best practices, and will be awarding “Smart Team” status to Youth Sports Organizations (YSOs) which have demonstrated a commitment to minimizing the risk ofphysical and psychological injury and sexual abuse to young athletes by implementing the best available knowledge and data to provide current best practices.

SmartTeams pilot program is for the Pre-HS athletes (ages 7-14). The Pilot programs will be for select football teams and the national rollout will be with all sports teams (soccer, ice hockey, baseball, lacrosse, etc) in 2015.

During my decade of formal education and subsequent years practicing, I’ve learned that the world of medicine can have similar governmental “bipartisan issues” of not reaching across the aisle to help out a fellow clinician.

The “great ones” across all aspects of medicine seem to have common attributes- professionally and personally. A clinicians ability to listen and be appropriately empathetic while having passion for their field of medicine is rare. Couple this with the desire to learn from others from multiple disciplines and this empirically leads to success for patient outcomes, professional growth, and knowledge translation.

I was both humbled and impressed by Ms. De Lench’s passion and abilities to put together such a comprehensive summit from all walks of life ranging from Harvard physicians, collegiate athletic trainers, an internationally recognized physical therapist, lawyers, neuropsychologists, nutritional experts, motivational speakers, and professional athletes all coming together with the common goal of addressing the youth athlete from an all encompassing holistic approach of mind, body, psychological, emotional and sexual well-being.

I am so very fortunate that I am able to surround myself with inspirational individuals across all aspects of medicine who are innovators in their fields via connections I have made across social media, residency, academia, and alongside my colleagues and associates I am lucky to work with everyday.

It is apparent that Ms. De Lench has similar attributes and has also surrounded herself with a strong group of individuals from all over the country. The central tenet from the inaugural MomsTeam Youth Sports Safety Summit was that it takes a village…or in this case a team of individuals from all walks of life to come together to advocate to the masses from a grassroots level.

If we practice solely in these silos that we set up for ourselves professionally across medicine, law, athletic training, coaching, government policy, and education then we will never be able to reach whole communities in such a positive way in which change needs to occur culturally, fiscally, and individually for the safety of our athletes.

I commend the incredibly comprehensive and still growing team of MomsTeam Institute for advocating and making change for the safety of athletes all across the United States.

Cheers to the continued growth, advocacy and gusto of all the participants who made the inaugural Youth Sports Safety Summit such a positive and educational experience.

Summative Themes and Highlights in 100 Words or less:

• Discussed the history and evolution of Sports Medicine • Discussed first epidemiological studies of sports injuries historically touching upon the Princeton v. Rutgers game of 1869 and Harvard v Yale in 1874 • Gracefully walked us along the historic perspectives of sport and injury prevention through the Greek, Renaissance and Modern times • We have athletically gifted athletes who are not fit and at a high risk for injury

Director of the Division of Sports Medicine at Boston Children’s Hospital; Clinical Professor of Orthopaedic Surgery at Harvard Medical School; O’Donnell Family Professor of Orthopaedic Sports Medicine at Boston Children’s Hospital; Secretary General for the International Federation of Sports Medicine (FIMS)

• We need to think like Sweden (the safest place to drive on earth). Zero needs to be our north star (regarding injury prevention across a lifetime)• 98% of kids will not be elite pro athletes. We can’t have our young kids doing sport specialization in their prepubescent years• ‘If you build it they will NOT come’ is the central tenet in public health: education is not enough• We need more comprehensive public health initiatives. If we bring together 3 public health strategies (see below), we will see injury prevention in our lifetime

• Sport specialization in early puberty develops the player, not the athlete. • Our kids are arriving broken even before the arrive through our doors at the NCAA level• Mental health issues are the #1 concern amongst our NCAA athletes

• Explains the important role of Neuropsychology in the Post-Concussive Athlete• Addresses the “workaholic” culture and challenges the audience and parents “Do we really know how to rest?” and “are we modeling this for our youth?”• Rest=best for concussion and delineates four key components of how to progress the student-adolescent athlete in a structured and overseen environment

Director, Sports Concussion Center of New Jersey, author of “Ahead of the Game: The Parents’ Guide To Youth Sports Concussion.”

• Females in sex comparable sports have higher rates of concussion than their male counterparts (basketball, ice hockey, lacrosse, and softball)• Concussed females are cognitively impaired 1.7x more than male athletes• You’ve evaluated an athlete on the field, now what? We must do due diligence and re-evaluate 24 and 48 hours post-injury

Associate Professor, Undergraduate Athletic Training Program Director, Michigan State University

• We need one singular goal: the development and implementation of policy in youth sports. Apropos policy changes can save lives• 90% of all deaths in sport are from four causes (cardiac events, TBI, and heat illness)• SMAC’s (sports medicine advisory committees) need to be comprised of sports medicine professionals like ATCs and MDs- not just policy makers who sit in a boardroom

Allison Maurer, MS, RD, CSSD, CSCS: “What Do You Mean, You Didn’t Eat?”: The ABC’s of A High Performance Diet

• Nutrition is the missing link for our student athletes• Our children are grossly overfed and severely undernourished• Food=FUEL. • We need to discuss fueling our athletes at 3 different levels: the athlete, the coach, and the parents

Sports Dietitian, University of Tennessee

Toben Nelson, ScD: Orange Slices and Hot Dogs: How the food environment in youth sports undermines its health benefits and what to do about it

• There is no difference in weight in our children who play a sport and who don’t. Our children are in an energy surplus• Adults need to shape healthy food environments for our kids• Provide youth sport volunteers with education to inspire real change

Associate Professor, School of Public Health, Division of Epidemiology & Community Health, University of Minnesota

• Commented on the tremendous socioeconomic benefits for communities who implement ACL prevention programs• $100/athlete savings w/respect to ACL prevention & screening programs see www.ncbi.nlm.nih.gov/pubmed/?term=24806006 for article • Updated the audience on the differences of the FIFA 11+ v. the old FIFA 11 • Discussed the importance of neural preparedness before going into practice/competition

Neeru Jayanthi, MD: Keeping Up With the Joneses: How Much Is Too Much in Youth Sports?

• We have to pay attention to the data at some point. Hours of training per week shouldn’t exceed a child’s age• The more specialized you are in sport the more predisposed you are to injury• It’s a perceived success with early sport specialization

• Discussed the power of coaches and entrusting them with the emotional welfare of her children• A call of action to create and sustain this social contract with our coaches and kids• Adults don’t have the market cornered on emotional maturity. We have to manage ourselves so we can role model for our kids.• Stand up for whats right when we hear youth using derogatory language and phrases like “that’s so gay” or “don’t be retarded”. Make these moments shocking and memorable

Best-selling author of Queen Bees and Wannabes and Masterminds and Wingmen: Helping Our Boys Cope With School Yard Power, Locker Room Tests, Girlfriends, and the New Realities of Guy World

• We need transformational coaches to teach our youth to win with humility and lose with honor• Coaches are educators. If we have student-athletes than we need teacher-coaches. We can’t just put a whistle in a math teachers possession and expect greatness. • Discussing old school belittling coaching practices: Is it best practice or are we just repeating what was taught and how it was delivered

We Can Do Better: A Multidisciplinary Proactive Medical Education Push in the Management of Sports Concussion Inspired by the 2014 FIFA World Cup

According to a July 10, 2014 press release from the American Academy of Neurology (AAN), “Physicians have an ethical obligation to ensure that their primary responsibility is to safeguard the current and future mental health of their patients” [1]. I’d like to extend this scope of practice to all healthcare practitioners, in particular, the Athletic Trainers (AT) and Sports Physical Therapists (PT) who are engaging, treating, examining and differentially diagnosing these athletes right on the sideline. Initiating conversation regarding this multidisciplinary push is apropos as the AAN just led the inaugural Sports Concussion Conference in Chicago, July 11-13, 2014, and did an excellent job discussing the multidisciplinary and multifactorial components of Concussion in Sport [2-4].

Alvaro Pereira, of Uruguay’s National Soccer Team, was the first and the most notable concussed athlete in the 2014 Fédération Internationale de Football Association (FIFA) World Cup. Pereira’s concussion was the concussion heard and felt around the world. Television newscasters and millions of people sitting in their local sports bars and living rooms around the world witnessed Pereira laying lifeless on the field after receiving a blow to the head during match play.

Unfortunately, Pereira’s concussion incident was not an isolated one during this 2014 FIFA World Cup. During the 27th minute of the Holland v. Argentina semi final, Javier Mascherano of Argentina collided heads with an opposing player losing balance and collapsing on the field. During the 16th minute of the Argentina v. Germany final, Christoph Kramer of Germany was blindsided by an Argentine player collapsing to the ground clearly dazed and in pain. Pereira and Mascherano’s concussions are of particular interest because these world class athletes were not only medically escorted off the field for examination, they returned to match play unlike Kramer who was benched for the remainder of the final.

I’d like to use the Pereira concussion incident to facilitate conversation amongst the medical community. Pereira’s concussion is of particular controversy because of his loss of consciousness (LOC), his dazed appearance, and blatant disregard for the sideline physician’s poor attempt to keep him out of the game.

Medical professionals that are a part of a comprehensive concussion management team (Physicians, Physical Therapists, Athletic Trainers, Neuropsychologists, Vision Therapists, etc) are educated that during an acute head injury where a concussion is suspected, an athlete’s cognitive ability may be transiently compromised [1]. This transient loss in cognitive ability is unsafe for the player in question as the injured athlete is often dazed, confused and displays poor kinesthetic awareness, thus making it unsafe for everyone around him or her.

World class athletes need to be represented by world class medical care. This leaves us with the glaring question that every medical professional should be asking themselves after the Pereira incident: how are we allowing players to make autonomous medical decisions during match play when they are clearly medically unstable?

If an elite professional soccer player who is visibly dazed and confused returns to play after being knocked unconscious on a world stage, what is happening at the youth, high school and collegiate levels?

Medical Presence on the Athletic Field:

In a 2014 position statement by the National Athletic Trainers’ Association (NATA): Management of Sport Concussion, Athletic Trainers should be present at every sporting event, regardless of level of play, age or sport [5].

In the United States, there are only a few states that mandate Athletic Trainers in middle schools and high schools. The timeliness of the NATA position statement coincides perfectly with the epidemic injury prevalence of anterior cruciate ligament (ACL) tears and concussions in our youth and collegiate athletes. Likelihood of an ACL injury in the female athlete is eight times [6] higher than that of their male counterparts [7] while there are 1.6-3.8 million sport-related concussions diagnosed per year [8].

Medical presence needs to become a priority for the safety of our children and athletes.

In the United States, youth coaches are often parents, volunteers, history teachers, gym teachers, athletic directors and so-on. The bottom line is that they have limited (generally a basic life support (BLS) CPR certification) to no medical background. How are we not advocating for the safety and rights of our children to have an Athletic Trainer present for all sporting events, including practices? How do we have the best medical personnel for our professional athletes and a glaring absence of coverage for our youth athletes?

Fiscal deficits are often the primary “rationale” for the lack of Athletic Trainer presence in school districts. A global educational push for parents, coaches, and school districts should be addressed with our vast and ever growing knowledge of concussion and athletic injury.

Protocol for an injured athlete for most school districts and tournaments in the state of New York is to dispatch for an ambulance via a 9-1-1 call. For non-emergent issues, this is not only a waste of precious time and resources for Emergency Medical Services (EMS) and the Emergency Department (ED), it is incredibly expensive bordering fiscally irresponsible for an athlete with a non-emergent injury to go to the ED. With an average ambulance ride 25 miles or under costing $858 [9] v. an approximate rate of $35/hr or $150/match for a Certified Athletic Trainer, hiring an Athletic Trainer appears to be the most ethically and fiscally responsible long-term action step.

Our job as medical professionals is to practice with nonmaleficence (do no harm). Ethically, it can be inferred that it is our job to step in and step up for our athletes during the most intense and heated game day situations. We are always mindful of case specific scenarios with regard to a multi-billion dollar event like FIFA’s World Cup or if their is a scholarship scenario for an athlete on the line pending injury report. With respect to sport concussions, we are aware of the potential short term and long term neurological sequelae of second impact syndrome [12], repetitive head injuries and/or subconcussive blows to the body that can result in serious neuropsychological, neurocognitive, and neurobehavioral deficits [10-11].

Second Impact Syndrome (SIS) occurs when an athlete suffers from another concussion while still recovering from the initial one. While SIS is rare, it can have detrimental or even fatal effects long term if a neuroaxonal injury is repeated during a time of acute injury or during the healing stage after the neurometabolic cascade [12]. Athletes, parents, coaches and school boards need to be thoroughly educated of the potential risks of the long-term neurological sequelae that can exist post-concussion.

Subconcussive blows, impact to the body not directly contacting the head, cannot be overlooked. While they are nearly impossible to be accounted for, both animal and human research models have elicited signs and symptoms of concussion in conjunction with damage to the central nervous system causing pathophysiological changes despite an absence of acute changes in observational behavior[13-15].

Using Pereira as a talking point, although he played on during the remainder of match play and did not have another direct blow to the head, soccer is a very physical sport. Man to man contact and accidental collisions occur on the field all the time. In fact, this is part of sport. As clinicians, we are aware that post-mortem research after head injury with repeated subconcussive blows have a cumulative effect [16] and may accelerate cognitive decline leading to an altered neuronal biology later on in life [17].

Let us stop to ask ourselves and educate our players and coaches, is it worth it?

Working with athletes who have undergone neurocognitive decline is heartbreaking. The powerful documentary Head Games: The Global Concussion Crisis is a powerful movie that illustrates the elite athletes plithe with neurocognitive decline and Alzheimer’s like degenerative disease. This movie can be easily accessed and used as an educational tool for the lay public and medical professional. The carryover is excellent and provides excellent question and answer opportunities for parents, coaches, and athletes to engage with their medical professional.

Medical Education for the Clinician Working with the Concussed Athlete:

The World Cup employs some of the top medical professionals in the world. If Alvaro Pereira was allowed to return to match play after exhibiting LOC, balance problems, appearing emotional labile, dazed and confused on a world stage, then we have some serious work to do as a medical community.

Alvaro Pereira apologized in a formal public statement to the Uruguayan physician the day after the match. Professionally, FIFA and the team physician should’ve reciprocated this apology to Pereira as it was ethically irresponsible for him to return to same day play sans rest, a full neurological and sideline evaluation. Players blatant disregard for medical opinion and feedback needs to be overridden by professional, medical, and legal protocols. Moving beyond the FIFA Concussion Recognition Tool, protocols leave no room for negotiation. Simplicity in prose, for example, if a player loses consciousness they cannot return to same day match play. Period. End of discussion.

At the youth and collegiate levels, there has been a recent push in concussion education for coaches. As of January 2014, all 50 states including the District of Columbia individually implemented youth sports concussion laws [1, 18]. On May 29, 2014, President Obama announced an initiative headed by the National Football League (NFL) and NATA to place Athletic Trainers in schools who do not currently have access to the appropriate medical professionals. Presently, only 55% of high schools have access to Athletic Trainers. It should be noted that access does not mean daily treatment and presence. Access can mean weekly visits to a school or a team. We need to do better.

As of July 1, 2014, The Indiana State Senate enforced a Bill to be the first state to require football coaches to participate in the “Heads Up” concussion training course every two years. “Heads up: Concussion in High School Sports” is a national concussion awareness initiative that started in 2005. It is a multimedia tool kit of educational flyers, videos, and fact sheets meant for coaches, parents, athletes, athletic directors and athletic trainers [19].

The implementation of individual state laws for youth sports concussion and mandating coaches participation in concussion awareness is an excellent step in a proactive direction with the safety of our athletes in mind; however, there needs to an increased focus on the medical professional and his or her role in taking charge of the athlete medically on and off the field.

It is unfair to place injury recognition responsibilities on the coach whose sole responsibility should be coaching. It is also unsafe for the player not to receive care by a certified medical professional who has the ability to differentially diagnose and identify the red and yellow flags necessary to keep the players short term and long term health and safety as number one priority.

Making a Proactive and Educated Change in Sport Culture:

A July 9, 2014 article published in Neurology discusses the paucity of skilled Neurologists who are comfortable with treating concussion [20]. It has been refreshing to work professionally with a wide array of medical professionals who have set aside ego while keeping the interest of education and patient outcomes a top priority.

Implementing multidisciplinary concussion management teams are going to be the future of fully comprehensive sport programs for athletes of all ages and abilities.

Educating ourselves as medical professionals is the first step in understanding multidisciplinary scopes of practice. Communication between a tightly knit team of Physicians, Physical Therapists, Occupational Therapists, Athletic Trainers, Neuropsychologists, Psychotherapists, and Speech Therapists will provide the best overall team outcomes for the concussed athlete who can experience an overwhelming array of physical, cognitive, social and emotional distress in a short amount of time.

A prime example of cross disciplinary education and interaction regarding concussion advocacy recently occurred with a colleague of mine who has the same passion for concussion advocacy and management. Katy Harris, M.S., A.T.C., is a seasoned Athletic Trainer who has a particular interest and expertise in sports concussion. She has exemplified the role of Athletic Trainer over the years with her ability to educate her athletes, coaches and parents on health and safety as it pertains to concussion.

Early in her career, Katy was the sole responsible Athletic Trainer for 400+high school and middle school athletes. While New York State does not require an Athletic Trainer in its public high schools, we need to be able to set up these qualified professionals for success and not career burn out. A common theme of frustration amongst Katy’s Athletic Training colleagues is wanting to provide the highest standard of care for all athletes, but not having access to or funding for delivering proper care combined with yearly job uncertainty due to frequent state budget cuts.

When discussing past memorable experiences regarding lack of concussion awareness amongst coaches and school districts, she immediately recalled a scenario when she happened to pass by a coach coming home from an away game. The coach informed her that one of his athletes was forcefully kicked in the head, had a headache, saw stars and was dizzy, but insisted he didn’t think it was a concussion and sent the child home. The coach dismissed the glaring prognostic indicators of a concussed athlete, not because he is negligent, but because he is not a trained medical professional. It should not be the job of a coach to make critical health decisions for his or her athletes.

When Katy was the supervising Athletic Trainer for a high school football team, she was in charge of 50+ boys at a time. If an injury was suspected or occurred, in order to reduce confusion on the field and to assert herself professionally, she would physically confiscate the athletes helmets so they were not able to return to play.

Katy’s exemplary action steps and advocacy for concussion education and management on and off the field is a lesson that FIFA’s World Cup legislators can take note of for future tournaments.

I look forward to being a part of the proactive concussion conversation in the years to come. In the mean time, lets continue to facilitate passionate multidisciplinary conversations at conferences, utilizing social media, continuing education across all professions, and accessing the medical professional at the entry level and residency components of their educational journey.

In conclusion, we can and will do better proactively educating ourselves as doctors and clinicians for the health, safety and future well-being of our athletes.

Concussion and Nutrition Series Part I: Evidence Behind Flavonoids and Their Role in Anti-Inflammatory Foods

When you visualize concussion treatment, what comes to mind? Physical rest? Cognitive rest? Pain relievers? Limitations in physical and social activity? Eating the right foods? I’d venture to guess that the latter is not on your list.

How can a traumatic brain injury (TBI) respond to food? Visualize treatments for cardiovascular disease and diabetes. Do nutritional interventions come to mind? I’d speculate that they do. The events happening in the body after a TBI are not all that different than many other chronic diseases. The common links are oxidative damage and inflammation. There is a growing body of evidence supporting antioxidant and anti-inflammatory diets as a way to prevent complications associated with traumatic brain injuries.

Let’s take a moment to understand oxidative damage and inflammation in the context of a concussion. After a TBI, an inflammatory cascade is set off as a healing mechanism. Although beneficial in the short-term, the inflammation can persist while the healing effects do not. This creates oxidative stress as too many cell-damaging free radicals lead to tissue damage and eventual cell death. In the case of a concussion, cognitive problems are common long-term complications [1,2].

Diets rich in antioxidant-rich foods may be useful approaches to promote protective mechanisms associated with TBI [3]. There is promising research that foods high in the class of compounds called flavonoids act on the inflammatory cascade and are linked to improving cognitive performance and lowering the risk of Alzheimer’s-a brain disease with similar symptom presentation with deficits in memory and thinking skills.

What Are Flavonoids?

Flavonoids are the pigments that give fruits and vegetables their color. They are the main reason why fruits and vegetables are considered to be so healthy. There are over 4,000 compounds considered to be flavonoids. The more deeply colored the fruit or vegetable, the more flavonoids it provides. They are also abundant in garlic, teas, spices, nuts and beans.

Flavonoids are antioxidants that are also anti-inflammatory. In a human randomized controlled trial, the flavonoid resveratrol, was shown to exert anti-inflammatory and anti-oxidative stress in humans [4]. Flavonoids, like all antioxidants, work by stopping free radicals from damaging cells, including neurons. Flavonoids are neuroprotective because of their ability to turn down inflammation and increase cognitive function via two processes. The first is by preventing the neuronal cell death that occurs during the inflammation-signaling cascade. The second is to induce the blood flow needed for new nerve cell growth to prevent or reverse loss of cognitive performance [5].

Consuming flavonoid-rich foods has been associated with the delayed onset ofAlzheimer’s disease, while some studies have linked them to improved mental function [6-9]. Although the research specifically linking brain traumas to flavonoids is at an early stage, we know that a diet rich in fruits and vegetables is invaluable for health and to prevent other inflammatory-related diseases (i.e. cardiovascular disease, diabetes, cancer). If not for the long-term, the short-term effects of eating the foods that are high in flavonoids will at the very least help the concussed patient have higher energy levels, to combat fatigue and to feel as well as possible.

Diet v. Supplementation?

Since fruits and vegetables are healthy and also high in flavonoids, it should follow that flavonoids are also healthy and the more you ingest the better off you’ll be. Shouldn’t flavonoid supplements be a fool proof way to make sure that you get enough of them? It is important to consider that we don’t yet know how the body responds to the high blood levels reached all at one time when we take a supplement. Visualize how flavonoids enter the bloodstream through healthy foods eaten consistently throughout the day- the spike in the bloodstream is never reached to that same level as when a supplement is taken.

It is also important to understand that fruits and vegetables have thousands of phytochemicals, many of which we have not even been identified. So taking one type of flavonoid in high quantities is unlikely to have the same health benefits as eating the whole food [10]. There is no such thing as a ‘silver bullet’ and we have to be very careful when choosing to supplement, especially when little is known about safety, contraindications, interactions, or effectiveness. Save your money and invest in colorful, delicious, flavonoid-rich foods instead.

When it comes to flavonoids, more colors mean more antioxidants. Here are some quick ways to add flavonoids to your day:

My name is Jessica Schwartz and I’d like to take a moment to introduce you to PT2Go!

You can find the mission statement here; but first, I’d like to share how PT2Go has organically developed over the last several years.

Conceptually, I thought of this intellectual space of PT2Go as I entered Orthopaedic Residency in 2010. During residency, I learned to truly appreciate the multidisciplinary communication, candor and enthusiasm across all aspects of medicine. After 10 years of formal education and 3 degrees later, I can honestly say that I was never a great self-directed learner.

During residency, I learned how to reason and think differently. In my first 3 months of intensive learning and direct supervised practice, I had become a completely different clinician than I was the day I walked across the stage at graduation and donned that famous doctoral hood. Despite the lack of sleep, buckets of coffee, and stress of having one too many things on my plate at any given time it was an honor and a joy to have learned and grown clinically with my class of residents.

After graduation from residency, I had a dilemma. I didn’t have someone telling me what to learn, how to learn, and there was no standing on the firing block for weekly peer review and feedback.

I had become incredibly efficient at work and I had rejuvenated my long lost social life with family and friends, but there was something missing. The work, life…learning balance. Where would I fit the time in for learning? How would I do it on my own? How would I do it efficiently?

THIS is where PT2Go comes in.

My goal is to promote the field of Physical Therapy in a collaborative and multidisciplinary way. I hope that by sharing some of my own self-directed learning experiences: the good, the bad, and the ugly (and believe you me I’m talking ugly!) I can assist in fostering interdisciplinary connections and conversations similar to the connections I made during my time as a resident.

Here is what you can expect*:

• High Yield Evidenced Based information that you can attain on-the-go

• Opinion (Op-Ed) articles that may push the envelope, foster passionate conversation, and encourage thinking outside of the box

• Tips on how to use and integrate Social Media and Medicine (#SoMe) for the Millennial and Generation X Learner

• A series on my own Post-Concussive-Syndrome experience. The Dichotomy of The Doctor Becoming The Patient: A Shared Experience of Personal Moments with an Evidenced Based Twist

• Concussion Story: A collaborative space for survivors and health care professionals to gain insight into the lives of their patients

• Links to Clinical Prediction Guidelines and tips on how to access the information we need in the clinic in real time

• A holistic approach to food and nutrition in medicine: taking care of ourselves, food and environmental responsibility, and how it relates to our patients

• Collaborative Case Studies

And much, much, more…

So cheers to you for coming on this self-directed learning experience with me. I hope to share my passion and authentic curiosity for medicine as well as facilitate passionate conversation with the intention of creating better clinicians and self-directed learners all around the world.